The Penn Orthoplastic Limb Salvage Center (POLSC) is among a handful of programs in the nation that combines the principles and practices of orthopaedic surgery and plastic surgery to encompass the preservation and practical restoration of the limbs, hands and feet.
What is Functional Reconstruction?
Functional reconstruction is a specialty devoted to restoration of range of movement, weight-bearing capacity, sensation and organic strength in the limbs and appendages. Many patients requiring functional reconstruction have lost range, strength and/or sensation in their limbs or appendages due to aberrant healing processes, such as scarring, nonunions and malunions as a result of trauma, or cancer and its treatment.
“These are extremely complicated cases,” says Stephen J. Kovach III, MD.
Along with fellow co-directors L. Scott Levin, MD, Chief of Penn Orthopaedic Surgery, and Samir Mehta, MD, Chief of Orthopaedic Trauma, Dr. Kovach plans and performs limb reconstruction procedures at the Center.
“What’s unique about patients seeking functional reconstruction is that their injuries can’t be resolved by any single surgical specialty,” says Dr. Kovach. “Our advantage is having the expertise not only to address these issues in a single location, but often as one-stage procedures, which means faster recovery and better outcomes for our patients.”
Whatever the cause, the goal of treatment at the Center is to restore the patient’s limb to optimal functional status.
What is Functional Microsurgery?
Microsurgery is a foundational modality of orthoplastic surgery. In 2000, Dr. Levin was among the first to use the term orthoplastics to define the fusion of orthopaedic and plastic disciplines. He observed that “microsurgery and creative thinking have now combined to address limb function and aesthetics.”
Specialists at the Center offer surgical techniques and innovations developed, in large part, through the practical experience, research, advanced training and interdisciplinary collaboration available at Penn Medicine.
“Our skills and teamwork set us apart,” says Dr. Levin. “On any given day, our surgeons are collaborating to perform complex microsurgical procedures, bone reconstruction surgeries and combined approaches unrivaled in the Philadelphia region.”
How do you treat a soft tissue injury?
Patients with soft tissue defects lack adequate muscle, fascia and skin coverage to allow limb extension or flexion of the hands and feet.
The Center offers microvascular perforator flap surgery, free functional muscle transfers and microsurgical reconstruction of soft tissue and muscle to treat patients with soft tissue defects.
“Typically, microsurgery at the Center involves reconstruction with pedicled musculocutaneous perforator flaps,” Dr. Kovach says.
These procedures transfer healthy tissue, blood vessels and nerves from other areas of the body to the extremities to restore function, form and tensile strength to the limb.
To minimize the morbidity of retrieving soft tissue, and better ensure flap survival, POLSC surgeons assess the patient prior to surgery to determine the best available donor site for the flap. The nature of the injury will determine the type and extent of microsurgical intervention; the surface area of tissue deficiency will determine the type of flap to be selected.
Criteria for Microsurgical Nerve Grafting and Nerve Transfer
Patients with upper extremity nerve damage caused by avulsion, laceration or contusion are candidates for microsurgical nerve grafting and nerve transfers to restore function to the limbs. For injuries exceeding 6 to 9 months from onset, the Center offers gracilis functional free muscle transfer (FFMT) in coordination with Penn Neurosurgery.
When Your Patient Has Nerve Damage from Cancer Treatment
Cancer surgery or trauma can result in nerve damage manifesting as chronic pain, loss of sensation and motor function in the limb. When motor nerves are affected, the potential for irreversible atrophy in the limb exists if not restored within 6 to 9 months of injury.
By applying neurosurgical techniques, orthoplastic microsurgeons at the Center can reconstruct nerves by connecting functioning nerves to the damaged nerve in the limb (neurorrhaphy), or through autogenous nerve transfer. Autogenous nerve transfer is when functioning nerves are transferred from other regions of the body to replace nonfunctioning nervous structures. Nerve reconstruction is often used in reanimation surgeries.
Effects of Radiation and Excision Surgery: Limb Function Restoration After Cancer Treatment
Treatment of sarcoma and sarcoid tumors may involve radiation and heterogeneous surgical resection of muscle, bone, nerves or soft tissue. This can result in substantial bone and soft tissue defects. Nerve damage is also a possibility.
Such cancer treatments are a common cause for limb function therapy at the Center, especially for sarcoma and sarcoid tumors patients experiencing the effects of radiation and excision surgery.
Soft tissue coverage and bone reconstruction are essential to address the significant tissue loss that attends sarcoma surgery. But before reconstruction can occur, a brief healing period and the timely application of adjuvant radiotherapy must take place at the surgery site.
Despite the challenges of limb function restoration following preoperative radiotherapy, Dr. Kovach attests to excellent outcomes at the Center with innervated free or pedicled musculocutaneous flap transfers.
“Many times, radiation changes are lifelong,” says Dr. Kovach. “But once we remove the radiated soft tissue and replace it with a nonradiated, supple microvascular pedicled soft-tissue flap, patients can put these wounds behind them and go on with their lives.”
Consulting with an Expert from Penn Medicine’s Orthoplastic Limb Salvage Center
The signs of functional impairment can be masked by other concerns and issues for patients and caregivers facing the debilities of cancer therapy over time. For patients with bone and soft-tissue cancers of the extremities, expedient follow-up with surgeons trained to recognize the subtleties of limb impairment and dysfunction is both needed and recommended.
“We can do amazing things here at the Penn Orthoplastic Limb Salvage Center,” Dr. Kovach explains, “but only if patients reach us before irreversible nerve and muscle atrophy can take place.”
Refer a Patient for Limb Function Treatment
When referring patients to the Penn Orthoplastic Limb Salvage Center for limb function treatment, refer them sooner than later.
In the wake of cancer therapy, scarring and nerve and muscle atrophy can worsen over time if not properly addressed.
“Far too many of our patients arrive here in the delayed setting with a poorly functioning limb from surgery or trauma-related extremity injury that hasn’t healed correctly after previous provisional surgeries or inadequate stabilization,” says Dr. Kovach.
To consult about a patient, call 215-294-9625 or email the clinical team at POLSC@uphs.upenn.edu
To refer a patient to Dr. Kovach, call our 24/7 provider-only phone line at 877-937-PENN (7366). You can also refer your patient for consultation via our online referral form.
[1.] Seminars in Surgical Oncology 2000; 19:272–281]
Additional Resources on Functional Limb Restoration